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23366 Commerce Park,
Suite 200
Beachwood, OH 44122
Phone: 1-216-397-5890
Fax: 1-216-464-0095
Toll Free: 866-428-8614

Insurance License #14365

On-Line Health Insurance
Quotation Form
One Simple Form - takes only 2-3 Minutes!

Your Personal Data

Your Name:
Street Address:
State: (Must be Ohio)
Zip Code:
E-Mail again for accuracy:
Fax (optional):
Marital Status:
Single Married
Do You Own Your
Own Business?

Yes No
Health Ins. Currently?
(If yes, list carrier, and # of years
continuous. If none, type N/C)

Insured Name: Birthdate:
Insured Height: Insured Weight:
Insured Occupation: Hazardous Activities? (if yes, describe):
Sex (M/F): List children's
ages to be covered
Be as specific as you can on the underwriting questions below so we may find the most competitive product for you!
Do You use tobacco? Yes No Describe usage (cigar, cigarettes, etc.)
Any Pre-existing Health Conditions?
(If yes, descibe in detail, and to which of the insured persons they apply.)
Any Covered Persons Currently Taking Medication of Any Kind?
(If yes, descibe in detail, and to which of the insured persons they apply.)

How Long Do You Need Coverage For?
(if short term, etc.)
What Deductible Do You Want?
($250, $500, $1000, etc.):
Any special coverages needed?
(Maternity, H.M.O., P.P.O., etc.)
Tell Us What You Want MOST in your Health Plan, or list any other Remarks here:

Send my quotation via: E-Mail Fax
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Thank you for filling out this form COMPLETELY!

We value your input as PRIVATE information. Every step has been taken to insure your privacy, security, and our intent is to release quote information only to you. We will not give your data to ANY other person or group for sales, marketing, or ANY other purposes. By checking the box below you agree to allow our agency to release this information via the method you have chosen, and to release us from any liability should this information be accidentally viewed by others. Our intention is to maintain your complete privacy.

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Health Insurance Quote NOW!

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